I've got a 2.5 year old male patient, presented with lt parotid swelling, CT scan revealed 1.3 cm intragladular stone. The swelling is 6 times recurrent. Any suggestions for optimal treatment?
A 1.3 cm claculus is unusual and there is bound to be quite substantial inflammatory fibrosis if there has been 6 episodes of sialadenitis. It may be possible to retrieve this by sialoendoscopy (if the technique is easily available to you - it certainly isn't universal) or basket retrieval at sialography (again if the technique and expertise is available). Calculi this size surrounded by inflammed and fibrosed tissue are often not easily retrievable by these methods and the situation can sometimes be made worse. If these fail a direct approach to the duct by raising a standard parotidectomy skin flap and identifying the buccal branch of the facial nerve which lies running in parrallel with the duct allows direct visualisation of the duct and removal of the calculus by a linear access incision in duct which can be repaired microscopically. My experience has been that this is comparitively quick definitive solution and as long as the duct is well repaired salivay fistula has not been a problem. The older approach of cannulating the duct, everting it out to the cheek and approaching the calculus by a transfacial incision carries a much higher risk of parotid fistula, is less aesthetic and risks the buccal brach of the facial nerve being traumatised.
Please check for blood parameters for calcium and other related enzymes... to rule out any calcification tendencies
I totally agree to all the above that sialography and sialendoscopy need certain expertise to get them done and if this is a child as much as i understand, then they might even need a general anaesthesia , so I would might as well do it surgically. The real question, is that if this is a child with all this, does the child manifest chest symptoms or any suggestive of congenital oral abnormalities, need to exclude bronchiestasis with sialectasis , abnormal oral or salivary gland architechure, which might need a sialogram, so just injecting dye through the duct opening of both parotids prior to doing the procedure.
Secondly, you mentioned the stone was intraglandular, which means that the only approach was going to approach it through the gland externally, so if there is a congenitally affected gland that will have a high tendency to recur again thn I would have thought a superificial parotidectomy would be the best long term plan, if all these elements were present.
This is a very young age for salivary stones.If no contributing factor is found try to manage as conservatively as possible.Sialogram and sialoendoscopy will involve a general anaesthtic for this young patient.Juvenile Recurrent Parotitis is self limiting and can be bilateral.Superficial partidectomy could become a difficult procedure as there will be significant fibrosis due to recurrent infection.As such the facial nerve is at significant risk of damaging.
I wonder whether there is a place for lithotripsy.If it is possible it should be considered as well. .Sialoendoscopy and removal og the stone is the other option.
Thanks kumara. The lithotripsy is contraindicated as this procedure could damage the facial bones.
Dear Mohammed Al-Khawalde,
a lithotrispy is definitively not contraindicated. We have performed it many times also in children in our hospital (ENT-Department, Erlangen Germany) in the past without problems.
The treatment algorithm in our department in this case would be: first sialendoscopy in general anesthesia. If the stone is intraglandular it is very unlikely to be removable so we would perform a lithotripsy simultaneously. In case of persisting problems we would perform a second course of lithotripsy in 2-3 months.
The third step would be the combined endoscopic-transcutaneous removal of the stone and the reconstruction of the duct as described by David Mitchell above.
A sialography is obsolete in our eyes and an operative removal of the gland only very rare necessary.
Literature:
Combined endoscopic-transcutaneous surgery in parotid gland sialolithiasis and other ductal diseases: reporting medium- to long-term objective and patients' subjective outcomes. Koch M, Iro H, Zenk J. Eur Arch Otorhinolaryngol. 2013 May;270(6):1933-40.
Sialendoscopy in the diagnosis and treatment of sialolithiasis: a study on more than 1000 patients. Zenk J, Koch M, Klintworth N, König B, Konz K, Gillespie MB, Iro H. Otolaryngol Head Neck Surg. 2012 Nov;147(5):858-63.
I think endoscopy through the duct plus preauricular approaches to retrieve the stone keeping the the gland in situ
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